Given prevailing Progressive Era attitudes towards physcially challenged individuals, the the Western Pennyslvania Institute for the Blind (WPIB) was a naturally isolated facility. WPIB was not geographically isolated however, and existed (and still does) in the middle of a busy section of Pittsburgh. We identified the WPIB as a provisional escape community, but the amount of information on the institution during the 1918-1920 influenza epidemic is rather limited.

At a Glance
Type of Site: Small, co-ed school for blind children in Pittsburgh, PA.
Population: 179 students; faculty and staff also lived on-site.
Pop. Density: N/A
Geographical Considerations: WPIB was an enclave restricted to faculty, students, and known visitors. Visitors were prohibited during the second wave of the pandemic.
Influenza Cases: 12
Influenza Deaths: 0
First Reported Case: Late-November 1918.
NPI Implemented: After several children returned with influenza after Thanksgiving, the school closed for one month (including the Christmas holidays).

Case Study
The Western Pennsylvania Institution for the Blind (WPIB) was chartered in 1887. In 1894 the school moved to its permanent home in the Oakland section of Pittsburgh, a thriving commercial and residential district and the cultural and educational center of the city. In keeping with the school’s mission, WPIB offered academic as well as commercial and industrial training to its students. Now called the Western Pennsylvania School for Blind Children, this facility remains open today.

The cloistered nature of the institution itself, its relatively small size, and a swiftly enacted protective sequestration policy all contributed to WPIB’s escape of the influenza pandemic, even as the disease ravaged Pittsburgh. Early in the pandemic, school officials announced that visitors would not be allowed to enter the school nor students allowed to go home for weekends. As a result of being effectively shut off from the rest of the city, no cases of influenza appeared in the school during the period of protective sequestration.

Although there is no recorded documentation, we learned from our tour of the extant building and meeting with the facility’s current Executive Director, Dr. Janet Simon, that there were on-site living facilities for the headmaster and his family. In addition, there were living quarters for the faculty and staff members, many of whom, as was the custom of the day, were probably unmarried women and men. It seems likely that the majority of the faculty and staff were placed in protective sequestration along with the students. We did uncover evidence that in the summer of 1918 the school installed a cold storage and refrigeration plant, allowing for the storage of large quantities of food. This may have played an important role in the institution’s ability to seal itself off from the rest of Pittsburgh.

By late November, as the epidemic in the Pittsburgh appeared to abate, the protective sequestration of WPIB was lifted and students were allowed to travel home for the Thanksgiving holiday. Upon their return in early December, however, 12 cases of influenza were diagnosed among the WPIB students. As a result, officials immediately closed the school for one month and scheduled the re-opening for after the Christmas holiday. When students finally returned to school in early January 1919, the epidemic was almost over in the Pittsburgh area and no new cases appeared at WPIB. There were no influenza-related deaths at the school during the second wave of the pandemic.

Research Materials
The amount of primary source material relating to the Western Pennsylvania Institute for the Blind in the 1918-1920 influenza epidemic is minimal. Because it was located in the middle of a Pittsburgh neighborhood, we also conducted research into how that city coped with the epidemic. Digitized sources include:

Newspapers:
Pittsburgh Gazette Times
Pittsburgh Sun

Archival Material:
Western Pennsylvania Institute for the Blind Annual Reports

Boxing match on the ship's forecastle, while she was at sea in the Atlantic Ocean, transporting troops to or from France in 1918-1919. Spectators are wearing masks as a precaution against the spread of influenza.

Summary
The 1918 influenza epidemic was a historic, health and demographic
landmark in South Africa. In Mamre the mortality rate
was 39/1000, which was similar to the rate in Cape Town.
The male/female ratio was 1,33, with males between the
ages of 20 and 40 years accounting for 60% of deaths.

The influenza pandemic took a terrible toll on Samoa’s population. Over a single week, prominent businessman and community figure O.F. Nelson had lost his mother, one of his two sisters, his only brother and a daughter-in-law. S.H. Meredith lost seven close relatives. Of the 24 members of the Fono a Faipule, only seven survived the pandemic.

James Ah Sue

James Ah Sue was the son of Samoan and Chinese parents. He was educated at the Marist brothers' School at Mulivai, where his contemporaries included O.F. Nelson and S.H. Meredith.

After leaving school, Ah Sue served his apprenticeship as a reporter with Samoanische Zeitung, an Apia-based weekly newspaper established by the German administration in 1901. Later he went to Suva where he gained experience with the Fiji Times.

When the Samoa Advance Party of the New Zealand Expeditionary Force captured German Samoa on 29 August 1914, Ah Sue was back in Apia and editor of Samoanische Zeitung. After its final issue was published on 2 January 1915, he became editor and owner of its English replacement, The Samoa Times.

Unusually, the 22 November 1918 issue of The Samoa Times did not appear. The following week, the newspaper reported 'with deep regret' the death of James Ah Sue. On 15 November, he had 'published the paper in good time. Having done so, however, he collapsed, grew steadily worse day by day, and died.'

Deceased was kindliness itself and generous to the point of fault, and in these dark days of tribulation, when the revenging hand of Death has seared so many hearts, the passing of James Ah Sue touches us closely with a sense of profound pity and sorrow.
- The Samoa Times, 7 December 1918, p. 3

James Ah Sue was survived by his wife and 10 children. He was 41 years old at the time of his death.

Mare Island Navy Yard, the oldest U.S. Navy base on the West Coast, was founded by CDR David Farragut in 1854. The Yard was located across the Napa River from Vallejo, CA.

From the founding of the Navy Yard, Vellejo was a "Navy town." The yard civilian work force largely populated the city. Yard workers dominated city political, economic, and social structure. A lively social life between Navy personnel and the civilians of the city flourished.1

The Spanish Influenza epidemic

Next to HIV-AIDS, the 1918-19 epidemic was the worst public health disaster of the 20th century. Estimates put American influenza deaths at 675,000, mortal to more Americans, by far, than all the wars fought in that century.2

Several phenomena new to the 20th century contributed to the rapid spread of the contagion:

- Masses of personnel were being moved in multiple directions around the world as the Great War was being fought.

- Large groups of coughing and sneezing people attended war bond rallies and parades.

- Movies encouraged people to gather in groups, all the while promoting the transmission of the virus.

- In a Navy town like Vallejo, several dance halls provided the opportunity for the spread of contagion.

A less virulent influenza epidemic in the spring of 1918 had but little impact on military or civilian personnel, thence on public health thinking.
Accordingly, when the much more virulent form attacked in the autumn, health officials did not take the occurrence very seriously, and were late to institute appropriate public health measures to slow the contagion.

Preparations on the Mare Island Navy Yard

On 23 September 1918, the senior medical officer at Mare Island received a letter from the Naval Training Center at Great Lakes, which reflected the Great Lakes experience: 20 percent of the yard's manpower complement would become infected, and of those afflicted, 10 percent would develop pneumonia.3 The Mare Island medical officer and his assistants quickly calculated that they should prepare to care for as many as 1,600 influenza victims and 160 pneumonia cases. They immediately began planning for two "emergency hospitals" to supplement the permanent 200-bed Navy hospital, which would care only for the most ill, those with pneumonia.4 Calls for additional corpsmen, nurses, and medical officers went out.

The Navy yard commandant published instructions on how to recognize the symptoms of disease and what to do if they occurred. Any person presenting with upper respiratory-like symptoms was to be hospitalized and quarantined.

Things were thus in readiness when the first case of influenza, a Navy corpsman returning from leave in Oklahoma, presented at sick call on 25 September 1918.

Conditions in Vallejo

The situation in the City of Vallejo was quite different. Not only had little or no advance planning occurred, but the solitary local hospital, a very small facility, was under quarantine because of a small pox outbreak there, and doctors were involved in a smallpox vaccination program.5
At the same time, just as the epidemic began to break out, the city was filled with patriotic fervor over the Fourth War Bond Drive, for which large groups of people frequently gathered.

Housing in the city, whose population had swelled by the influx of 8 to 10 thousand war workers, was crowded and inadequate. Some workers and their families were housed in quickly constructed shacks; others lived in tents thrown up in the backyards of established homes.6 Crowding and its attendant spread of contagion was inevitable.

Because there was nothing, early on, to differentiate this virulent strain of flue from the "ordinary influenza prevalent here at various times",7 no provision for quarantine was made.

The first civilian cases, two, occurred on 27 September, according to the yard medical officer report. The local press reported the outbreak on 4 October.

The Epidemic Runs Its Course at the Navy Yard

With the diagnosis of influenza in the community, Navy authorities quickly responded. Liberty in the city was canceled and functions involving large groups of personnel were prohibited. On 5 October the emergency hospitals were opened. The peak of the epidemic among service people in the yard was around 13-15 October, and it was virtually ended by 30 October. There were 1,536 (1,600 predicted) service personnel treated for influenza. An emergency hospital for civilian employees of the yard opened on Navy yard grounds on 3 November and closed 30 November. Two hundred eighty-seven civilians received care.8

The Epidemic in Vallejo

As the first few influenza cases appeared in town, physicians, with assistance from three Navy surgeons, were vaccinating all school children against the local smallpox epidemic. Local press reports indicate that the vaccination program was successful; after 4 October no new smallpox cases were reported.9

Attention could now be directed to fighting influenza. On 4 October, the Vallejo Evening Times headlined "Fumigation of Public Buildings in Next 48 Hours." The Navy medical officer decried this procedure as a futile gesture and complained in his report to BUMED that local authorities were ignoring advice from naval authorities to institute effective public health strategies. However, on 8 October, by City Council resolution, public authorities did close all public buildings. Church services, while not prohibited, were moved out of doors in order to reduce crowding. The press noted though, that no efforts had been taken to prevent the influx of contagion from outside the city.

In an editorial on 9 October, the Evening Times was reassuring. "There is no cause for alarm. As far as can be learned, no Spanish influenza is prevalent here and the steps taken [the closure of public buildings] have been taken merely as a preventative." The next day, however, the headlines reported 12 civilian cases. On 11 October, local Red Cross officials met to prepare for the coming onslaught by formation of an "influenza unit" involving physicians and nurses working in a local building which would be converted into a hospital, "should the need arise."

The need quickly arose as headlines, just 4 days later, declared "between 60 and 70 cases are being treated,"10 in their homes. It is probable that each civilian doctor made at least 60 house calls a day during this period. The 17 October Vallejo Evening Chronicle headlined that a 60-bed unit was to be opened, but noted that ". . . While medical officers of the [Navy] station think that a 60-bed hospital is a good thing to start with, they also state that if Vallejo hopes to care for her sick she should have at least 300 beds ready."

"City Emergency Hospital"

On 21 October, under the auspices of the Vallejo Red Cross, the Emergency Hospital was opened in an annex of the Y.M.C.A., "in an effort to concentrate the patients [according to the Navy special report] and thus relieve the wild running about of physicians, conserve nursing facilities, and provide hospital care for the sick." The Evening Times had a different take on the purpose of the facility, reporting that red Cross workers would look after those afflicted who had no homes and who were not eligible for care at the Navy hospital, that is, people who were not civilian employees of the yard. There are no records to indicate how many people were hospitalized there.

By 23 October, 350 cases of influenza were reported in town. The Vallejo Evening Chronicle reported that the Emergency Hospital was staffed by a single nurse, who had been on duty for 48 hours without relief. The President of the Vallejo Board of Health tried, without success, to obtain help in the civilian community.11 On the same day, about 1 month into the epidemic, the City Council directed the use of gauze face masks by all citizens. Non-compliers faced stiff fines.

October 24th found 20 patients hospitalized in City Emergency Hospital, many seriously ill with pneumonia. Still unable to properly staff the hospital with civilian workers, the Red Cross made an urgent appeal for help from the Navy Yard. Navy authorities quickly ordered six hospital corpsmen to assist at the facility. They found that it was "a deplorable place for patients. It was unheated, low ceilinged, poorly ventilated, poorly provided with nursing personnel, commissary, and toilet facilities."12 There was no effective administration, and the lead corpsman, a Hospital Apprentice 2d Class "stepped in and practically ran the hospital." Each private physician admitted, attended, and discharged his own patients independently, which troubled the Navy medical officer, who reported: "[s]uch lack of management and system gave rise to untold confusion and largely defeated the object of the hospital, namely to conserve the time and strength of the doctors and afford proper care of desperately sick patients."

The Evening Times reported that physicians were too busy to report accurate numbers of sick, "but indications are that several hundred are suffering."

The Crisis Worsens

By 26 October, Navy yard officials became acutely aware of the loss of a large number of civilian shipyard workers to illness. Navy doctors working in town reported they had discovered whole families ill, with no one to care for or feed them. They found unmarried Navy yard workers sick and unattended in rooming houses; at night, uninfected workers from the Navy yard would return to these same rooming houses, to share poorly ventilated quarters with the sick. In poorer areas of town, people were simply unable to obtain the services of doctors and had to fend for themselves.

The Evening Times reported that local physicians were overwhelmed by the number of calls they received, and noted that "one physician received 15 calls in 2 hours" in the evening.

Conditions were so serious by 30 October that three representatives, the local Red Cross Director, a local physicians (and Navy reservist), and a Trades and Labor Council leader, met with the City Council to "demand . . . that some steps be taken to alleviate conditions existing here at the present time . . .",13 and to "have the entire situation placed under the command of CAPT Harry George [the Navy Yard Commandant] to be handled by his medical forces."14 An editorial in the Evening Times concluded that "The summoning of the naval hospital unit should have been carried out several days ago, or as soon as the disease was well in hand at Mare Island and the physicians and their aides were at liberty . . . To answer the call of the people of the community."

"Saint Vincent's Navy Hospital"

The City Council acknowledged the inability of the city's resources to deal with the crisis, and requested the aid of the Commandant of the Navy Yard. At the same time, the local Dominican Order offered the use of a newly constructed school for another temporary hospital. The Commandant promptly authorized a 100-bed facility to be opened.15 The Navy provided 4 medical officers, 24 corpsmen, and 58 support personnel. Six Dominican sisters acted as nurses. This hospital opened on 2 November. Three days later it was caring for 71 patients.

The Epidemic Finally Wanes

No sooner was the new hospital opened than newspapers began to report a decline in the number of new cases of influenza in town. By the 6th of November the Evening Times editorialized that "reports of today on the influenza situation indicated that the epidemic at last is under control and on the decline." By 16 November the Emergency Hospital at the Y.M.C.A. annex was closed. The St. Vincent's unit still had 68 patients but was closed on 30 November. Its Navy staff and the Dominican sisters had cared for a total of 190 patients, including 80 women and 42 children.

A Brief Resurgence of Infection

In January 1919 the epidemic recurred. While few cases occurred at the Navy Yard, local resources were again quickly overwhelmed. Mare Island Navy Yard employees telegraphed the Secretary of the Navy on 10 January: "Vallejo Calif calls for help. Your Mare Island Navy Yard civilian men are dying. Wives and children lay stricken without help. Hospitals full, no nurses. Doctors working day and night. Please advise Commandant Harry George of Mare Island Navy Yard to quarantine Vallejo and take full charge. Live up to your good record and show us some action. Yours for service."16

In a City Council meeting on the 11th, the major of Vallejo stated "there is no provision in the budget for any emergency." However, the Dominicans again offered the use of their school, and on 13 January "St. Vincent Navy Hospital" was reopened. Face masks were again required, and theaters closed once more.

That same day the Commandant of the Yard reported to the Secretary of the Navy by telegram:

"Influenza in Vallejo serious and fast becoming epidemic. St. Vincent's Catholic Church has placed school building at disposal Commandant as temporary hospital. Large majority of residents are Officers and enlisted men Navy and civil employees Navy yard and their families, and immediate steps should be taken to afford them medical assistance. Request authority to maintain temporary Naval Hospital at St. Vincent's school and to expend necessary funds. Consider project most urgent to safe life and protect Navy personnel and civil employees."17

The Vallejo Evening Chronicle (January 13) editorialized that "[the Navy Yard Commandant] was quick, as he has been in all things, and at all times, to see the necessity for checking and controlling the new trouble." By 22 January the Evening Times headlined "NO NEW CASES REPORTED" and reckoned the quick demise of the epidemic was ". . . due to the systematic way in which the epidemic was handled . . ."18 Public places were re-opened on 25 January, and the St. Vincent's unit closed on 28 January. A total of 55 patients had been hospitalized.

Commentary

The Spanish influenza epidemic represented a public health emergency of the highest order.
Mare Island medical personnel properly prepared for the onslaught of expected influenza cases. They "got their Public Health right" in that all patients presenting with symptoms of influenza were promptly quarantined. Similarly, contacts with the community where infection was rife were curtailed early on. Civil health officials were not so well prepared. Nor were they open to suggestions from Navy medical personnel about how to organize their efforts. Because the U.S. is an "open society," however, local citizens successfully urged Navy intervention. Naval personnel performed magnificently, to the copious approbation of citizens and civic authorities alike.19

What of Today?

Our current concerns about possible terrorist-induced epidemic, or another SARS-like outbreak, throw the experience of Mare Island Navy Yard and Vallejo into high relief. A very contagious, virulent virus could produce so large a volume of illness so quickly as to overwhelm local medical capabilities.

In California there is "no specific authority" for public health officials to "deputize" or otherwise organize local medical personnel to respond to an emergency. While quarantine can be ordered with judicial approval, medical response to a public health emergency is [still] based on a "gentleperson's agreement" among the various parties.20 Country health officials and local hospitals work together developing action plans to be instituted in the event of a large public contagion.

Clearly, there could be a large role for military medicine in some future contagion. This would call for civilian-military contingency planning for such an eventuality. Strategies for a public health response and for the management of large numbers of very sick people must be put in place now.

In this program, a number of nurses and doctors recall the Spanish influenza epidemic which swept Australia in 1919. At least twenty million people died of the flu around the world, including twelve thousand Australians.

In the first half of that year, normal life in the country came to a standstill, as desperate governments tried to stem the spread of the disease.

Meteorologist Preston C. Day (1859-1931) wrote in December 1918, “The severity of the weather experienced during December and January of the winter of 1917-1918 over the greater part of the United States east of the Rocky Mountains, and also over much of Canada and Alaska during the early part of the period, was so unusual as to the length of time the low temperatures persisted, the great area involved, and the degree of cold maintained, that some discussion of the contributing factors, and comparison with similar occurrences of previous years, seems desirable.” (1-2)

Climatologist Charles F. Brooks (1891-1958) wrote in June 1918, “Even though summer is upon us, it is not difficult to recall that last winter in the United States east of the Rockies was remarkably cold and snowy. The first killing frosts of autumn came early, and nipped crops which had started late and grown slowly in the cold spring and early summer. The South had a real winter, much to the detriment of fruit and truck crops which were caught by frost.”

Brooks continued, “By far the most intense winter conditions occurred in the regions from the Ozarks to New England, where low temperatures brought snow with passing cyclones, and the snow cover in turn cooled the air excessively whenever the sky was clear…In the eastern United States it was not surprising that autumn months which in many regions were the coldest on record, should be followed by a December and a January that defied the memories of the oldest inhabitants. For example, in Ohio, a 64-year record fails to show a colder December, and in New England, January seems to have been the coldest month at least since 1836, if an Amherst record may be considered as representative.” (3-4)

I.Three Theories

The extremely cold winter of 1917-1918 preceded the three deadly waves of pandemic influenza in 1918. Influenza and all other human disease occur in a context, an environment, which must be conducive to a disease-causing germ’s ability to enter and thrive in the human body. Classical germ theory states that an outbreak of infectious disease occurs because the germ itself has changed, becoming more virulent. For example, current theory on the origination of the influenza pandemic of 1918 suggests the causative virus became more virulent via drift or reassortment, while the environment more or less remained constant. Classical environmental medicine theory by contrast states that what is going on in the environment is as important as the nature of the disease-causing germ. Disease outbreaks occur even when the causative germ remains essentially unchanged, because the environment has changed, permitting the germ to, well, germinate. A third theory is that germs and environments change together. For example, a cold winter may cause humans and hogs to cohabitate indoors where they aerosolize and inhale one another’s influenza germs, which exchange DNA to create a new subtype of influenza A to which both species are newly susceptible.

The purpose of this article is to document the reality of the unusually severe winter of 1917-1918 in the United States and its association in time with the subsequent emergence of pandemic influenza in 1918. The gravity of the winter of 1917-1918 needs further study as a factor in the emergence of the deadly pandemic influenza strain in 1918. Did humans and their livestock cohabitate in enclosed spaces on farms in Haskell County, Kansas, during the brutal winter of 1917-1918? Haskell is the place that some people believe the 1918 pandemic strain originated. (5-10) Was this cohabitation against the elements the opportunity for reassortment of genetic material between pig and human flu strains that produced the novel influenza virus of the pandemic of 1918? Did a new influenza virus to which immunity was lacking in most young adults arrive to the United States via icy winds that blew southward from the Arctic for two months?

II.Federal Censorship of the Press during the Winter of 1917-1918

Information in the print press about the influenza and other disease epidemics during the winter of 1917-1918 is limited because of the control of the release of information by federal authorities in the Wilson administration. The paucity of information makes reconstruction of disease events more challenging for medical historians. Meteorologists fared better because the information they developed and distributed was essential to military and civilian authorities.

The rationale of limiting what was published was to minimize the Central Powers (Germany and her allies) ability to know about any difficulties the United States was experiencing during its military and national war goods’ ramp up to fight Germany. The United States was wholly unprepared as the war came nearer and nearer to our shores. Much haste was involved in creating a conscripted army, because the U.S. entered the war so late, on April 6, 1917, compared with her closest allies, Great Britain and France (August 1914).

III.Weather Preceding December 1917

Prior to December 1917, says Dr. Preston Day, September was a cold month over much of the eastern half of the United States. October 1917 was also a cold month in all portions of the United States from the Rocky Mountains eastward. “In fact, it partook largely of the characteristics of a winter month in the great central valleys. Freezing weather occurred throughout nearly all portions of the country; the earliest frosts of record were reported from points in the Southwest; and unusually heavy snows occurred near the end of the month in the Lake region and northern Appalachian districts.” (1)

IV.Weather of December 1917

November 1917, however, was warmer than usual. However, “with the closing days of November there was a rapid fall in pressure over interior Alaska and the British Northwest, which quickly overspread the United States.” Then high pressure and intense cold entered the Arctic portions of Alaska and pushed their way southward into the United States, where the month of December 1917 was one of the coldest of record over a large area east of the Rocky Mountains.

On December 7, 1917, the strong high-pressure area moved southeastward in the wake of a heavy snowstorm, bringing during the following few days the coldest weather of the season to date into the Gulf and south Atlantic States. By December 12, 1917, cold temperatures of -20 degrees Fahrenheit to -30 degrees Fahrenheit advanced rapidly into the central valleys and as far south as Iowa and Nebraska. December 13th and 14th, 1917, heavy snow with high winds prevailed form the Lake region to New England, followed by marked cold within the succeeding few days, the temperature falling to nearly -30 degrees Fahrenheit in portions of New England. (1)

In the latter half of December 1917 (28th and 29th), high pressure again entered the northern portions of the United States between the Great Lakes and the Rocky Mountains, with barometer readings, reduced to sea level, above 31 inches, about 1 inch above the normal. At this time, temperatures ranged from -62 degrees F., on the Arctic Circle in Alaska, to -30 degrees F., or lower, in portions of Iowa and Nebraska, and to freezing on the south Texas coast. The cold wave extended to the eastern portions of the United States and Canada during the following few days, the temperature falling below -40 degrees F., in the heavily snow-covered northern portions of New York and New England, and to freezing in the central portions of the Florida Peninsula. This was one of the severest cold waves of record over the northern portion of the country from the Great Lakes eastward, particularly in New England.

Day notes three causes of the extremely cold weather of December 1917 in the United States east of the Rockies (the weather west of the Rockies was abnormally warm). First, the flow of air was unobstructed “from the intensely cold far Northwest into nearly all portions of the United States…In the Great Plans the winds were northerly from 40 to 70 percent of the time, and as far south as San Antonio, Texas, they were from a northerly point 60 percent of the time.” (1)

Second, the unusually extensive and deep snow cover over a large part of the eastern United States during most of the month presented a snow surface that favored rapid cooling of the air at night and by preventing appreciable heating by day, kept the northerly winds cold. Also, on account of the large amount of heat required to melt the snow, the infrequent southerly winds could not maintain their high temperatures.” (1)

Third, there was no departure from the normal amount of solar output of heat. “[I]n fact, at the most northerly station at which such observations were made, Madison, Wisconsin, there was an apparent slight excess of heat received from the sun as compared with the normal. This, however, is accounted for, in part at least, by the unusual dryness of the atmosphere, which favored increased transmission of the solar energy through it,” explains Day.

V.Effects of December 1917 Weather on Society: Food and Coal Scarcity, Soldiers Suffer

The heavy snow covering during much of the early part of December 1917 caused havoc with farming operations, particularly east of the Mississippi River. “Plowing was abruptly halted, and the husking of corn proceeded so slowly that at the close of the month a large part of the crop was still in the fields.” The United States had entered the Great War in April 1917, and any decrease in food production was a problem. “While the heavy snow-covering afforded ample protection to winter wheat over most districts during the colder period of the month, much damage from the severe cold was experience by the truck crops of the South,” notes Day. (1)

“Heavy snow and extreme cold in the principal coal-mining districts of the east interfered seriously with the production, transportation, and distribution of fuel. At the close of the month much suffering from the severe cold was being experienced, and many important industries were either partially or wholly suspending operations from lack of coal. Heavy ice had formed on most of the important northern rivers, and in the Ohio the conditions were reported as the worst in its history, gorges forming which held for many weeks.” An ice gorge is a mass obstructing a narrow passage.”

The unusual cold in December 1917 caused suffering among soldiers in the U.S. Army cantonments, even in those (the majority) that were located in the South to take advantage of the usually warmer weather there. For example, On December 20, 1917, soldiers at Camp Wadsworth in Spartanburg, South Carolina, complained they “could not obtain equipment to protect them against cold.” In addition to a lack of hot water for showers and food that was sometimes only lukewarm, the soldiers lived in tents, instead of comfortable wooden barracks, heated by a small, wood-burning stove. A New York Times article from December 20, 1917, reads, “Each tent holds a squad of eight men and a corporal. The canvas conical [teepees] are heated by a small circular stove, burning wood. During the [ten-day] cold snap, water left in the tents at taps was ice at reveille. Three days ago, the entire camp water supply froze, and the men were forced to go outside the reservation and draw bucketfuls from farm wells.” The article continues,

The men assert that most of the wood goes into the incinerator fire or the fires in the company kitchens, which eat up five cords a day and burn all night—cooking the oatmeal for morning. Contending that they are unable to get enough wood any other way, the soldiers sometimes steal the kitchen supply or raid a more fortunate company. Recently an order went out threatening wood stealers with punishment in the guard house; but the men say they must keep warm and the wood still disappears. (11)

Coal in New York City was becoming so scarce in the last decade of December 1917, Federal Fuel Administrator Harry A. Garfield gave sweeping powers to the president of the Chase National Bank and the Fuel Administrator for New York State to deal with distribution of coal. “The authority to handle any emergency without first communicating with Washington was given” by Garfield. (11) Coal was not moving quickly enough into the city because of the ice and severe cold. “The largest number of deaths [56] from pneumonia in twenty-four hours in New York in the last five years occurred between December 17 and December 22, 1917, noted Dr. Charles Bolduan of the Health Department.” He attributed this increase to “weather conditions, dampness and slush, and added that in many instances it resulted through carelessness on the part of those who would not take care of themselves after taking cold.” (12)

VI.Weather of January 1918

The weather got worse in January 1918. At the beginning of the month, snow cover extended over a wide area as far southwards as Tennessee and the Carolinas. An unusually low pressure over the southern districts of the United States caused a pronounced flow of cold air from the north into the central and southern portions of the country. On January 6th to 8th, a snowstorm further increased the depth of the snow cover. The coldest air of the season then moved down from the north. Snow was unusually deep east of the Mississippi River. January 11th and 12th witnessed very strong, cold, north to southwest winds prevailing over the middle portions of the United States, carrying the temperature to nearly -20 degrees F. as far south as Tennessee, and to 20 degrees F. or lower on the Gulf coast and in Northern Florida. In the Ohio Valley and adjoining regions, January 12 [1918] was probably the coldest and most disagreeable day experienced in a century, said Day.

It is scarcely possible to portray adequately the real penetrating character of the winds that blew with gale force all day, causing great suffering and even death to man and beast. It is true that at some stations the temperature has been lower on previous occasions than during this storm; at some the snowfall has been heavier on other occasions; and even higher winds velocities have been recorded, but rarely if ever has there been in this State a combination into which the principal weather elements entered with such force and persistency as during the cold wave of January 12, 1918. (1)

Unusually cold weather continued. Around January 20, 1918, a cold wave once again extended southward from the Arctic, bringing, in some districts, the severest weather of the winter. Cold air from the north moved swiftly into “the interior and Southern States, with little opportunity for heating, due to the expanse of the snow and ice covered areas over which it passed. Temperatures fell to -20 degrees F. in Nebraska and to freezing in southern Texas.” The period from about January 7 to 23, 1918 inclusive--17 days--temperatures in the east-central portions of the United States were almost continuously below normal.

VII.Effects of January 1917 Weather on Society: Food and Coal Scarcity, Soldiers Suffer

Day wrote, “At the beginning of the month the ground was snow covered north of a line extending from South Carolina to the northern Rocky Mountain region. Frequent extensive storms sweeping well to the southward in their movements across the country added to the depth and surface extent of the snow, and by the middle of the month [January 1918] the greater part of the country was covered” with snow. “The depths had reached unusual proportions in the Ohio and middle Mississippi Valleys and thence northward over the Lakes region and northeastward to New England. At points in these regions some of the heaviest snowfalls and severest drifting ever known occurred; and the great transportation lines were often badly crippled and at times completely paralyzed. Wagon roads were blocked for long periods, the distribution of food and fuel was greatly delayed and much actually suffering was experienced, particularly on account of the intense cold and the general scarcity of fuel.” (1)

Day continued,

Severe cold, deep snow, and the attendant disorganization of nearly all industrial activities persisted with only slight variations until the end of the month, except that during the last week some melting of the snow cover occurred over the southern drainage area of the Ohio and thence to northern Texas.

Much additional ice formed on the rivers and lakes during the month, and in some of the important producing sections the gathering of the crop was delayed because the thickness was too great to permit the use of the special implements employed in the work. On the Ohio and middle Mississippi Rivers the amount of ice at points was the greatest ever known. Gorges that formed in the Ohio early in December, 1917, held in some places throughout the month [of January 1918], and when they finally broke up late in January, or early in February, caused much damage to river interests. It is estimated that one-half the tonnage on the lower Ohio and portions of the middle Mississippi was destroyed by the heavy ice. At Cairo, Illinois, it is reported that pedestrians crossed the Ohio River on the ice, an occurrence not previously related either in the known history or traditions of that place. At the mouth of the Chesapeake Bay, where ordinarily no interruptions occur to traffic, there were 15 days during the month on which it was impracticable on account of the ice barriers to operate car floats between Cape Charles and Norfolk…

Farm work of all kinds remained practically at a standstill, much corn still remained in the fields ungathered, and wheat not protected by a snow cover was badly damaged by the cold. In the Southern States, winter oats were killed or their growth greatly retarded, and in the great winter trucking districts only the hardier vegetables made appreciable growth, and some that survived the cold of December were further damaged during January. (1)

VIII.February 1918 Weather

“For the month as whole the temperature averaged well above the normal over the greater part of the country, particularly in the central valleys, where it was in marked contrast with that of the preceding two months. The heavy body of snow on the ground at the beginning of the month disappeared rapidly, and at the close only the northern districts were snowbound. The breaking up of the heavy ice in the rivers and the discharge of the excess of water resulting from the large accumulation of snow was accomplished with much less damage and loss by overflow than had been feared, although in the Ohio and some it its tributaries the formation of several extensive gorges caused considerable damage.” (1)

“The milder weather of February brought much relief to the mining and transportation interests and greatly relieved the suffering from cold due to a general scarcity of coal and other fuels. Much progress was made in farming operations usual to the winter season, which had been practically at a standstill since early in December.” (1)

IX.Weather Winter 1918-1919

The winter of 1918-1919 was as mild as the winter of 1917-1918 was severe. “The winter of 1917-18 and that of 1918-19 were two extremes,” noted meteorologist Robert DeC. Ward in March 1919. (13) “Coal that in 1917-18 came to the coal ports solidly frozen in the cars had to be steamed out, sometimes to freeze again before it could be dumped into barges, flowed out last winter [1918-1919] as freely as it does in June and there was no need of the elaborate steam sheds that had been added to the railroad equipment in anticipation of another hard winter and a continuation of the wartime demand,” noted another observer. (13)

X.Summary

The winter of 1917-1918 in the United States east of the Rocky Mountains was one of the coldest, windiest, iciest and snowiest on record, ever. The worst influenza pandemic in known history, caused by a novel strain, occurred in three waves immediately following this extraordinary winter. Environmental factors and germs are equal players in a disease outbreak.

Notes:
1.Preston C. Day: “The cold winter of 1917-1918.” Monthly Weather Review, December, 1918, pp. 570-580.
2.Dr. Preston Day’s obituary is available at http://docs.lib.noaa.gov/rescue/mwr/059/mwr-059-10...; accessed July 23, 2009.
3.Charles F. Brooks: “Notes on meteorology and climatology. The ‘Old-fashioned winter of 1917-1918.’” Science, June 7, 1918, Volume 47, pp. 565-567. Available at http://www.sciencemag.org/cgi/reprint/47/1223/565....; accessed July 23, 2009.
4.Dr. Brooks’ obituary is available at http://www.jstor.org/pss/2561518; accessed July 23, 2009.
5.Jeffery K. Taubenberger and David M. Morens: “1918 influenza: the mother of all pandemics.” Emerging Infectious Diseases, January 2006. Available at http://www.cdc.gov/ncidod/eid/vol12no01/05-0979.ht...; accessed July 23, 2009.
6.“Influenza: Kansas—Haskell.” Public Health Reports, April 5, 1918, Volume 33, Number 14, p. 502. Available at http://www.pubmedcentral.nih.gov/picrender.fcgi?ar...; accessed July 23, 2009.
7.Public Health Reports was the predecessor of Morbidity and Mortality Weekly Reports (MMWR). The latter is published by the Centers for Disease Control and Prevention. The first Public Health Reports issue was published in 1878. For all issues, see http://www.pubmedcentral.nih.gov/tocrender.fcgi?jo...; accessed July 23, 2009.
8.John M. Barry: The Great Influenza. New York: Penguin, 2004, pp. 94-95.
9.John M. Barry: “The site of origin of the 1918 influenza pandemic and its public health implications.” Journal of Translational Medicine, 2004, Volume 2, Number 3. Available at http://www.translational-medicine.com/content/2/1/...; accessed July 23, 2009..
10.Janice Lee McClure (ed.): Haskell County, Kansas: A Historical Anthology; 100 Years beneath the Plow. Newton, Kansas: Mennonite Press, 1988, p. 295.
11.“Spartanburg men complain of cold; have warm clothing, they say, but tents are badly heated and hot baths are lacking.” New York Times, December 20, 1917.
12.“Sweeping powers given to fuel head; Dr. Garfield authorizes state administrator to close ‘luxury’ industries; priority in coal orders; domestic consumers to have first call—deaths from pneumonia increase.” New York Times, December 22, 1917.
13.Robert DeC. Ward: “Meteorological observations while traveling.” Monthly Weather Review, March 1919, Volume 47, Issue 3, pp. 170-171. Available at 701.http://docs.lib.noaa.gov/rescue/mwr/047/mwr-047-03...; accessed July 23, 2009.

The site of origin of the 1918 influenza pandemic and its public health implicationsJohn M Barry

The 1918–1919 influenza pandemic killed more people than any other outbreak of disease in human history. The lowest estimate of the death toll is 21 million, while recent scholarship estimates from 50 to 100 million dead. World population was then only 28% what is today, and most deaths occurred in a sixteen week period, from mid-September to mid-December of 1918.

It has never been clear, however, where this pandemic began. Since influenza is an endemic disease, not simply an epidemic one, it is impossible to answer this question with absolute certainty. Nonetheless, in seven years of work on a history of the pandemic, this author conducted an extensive survey of contemporary medical and lay literature searching for epidemiological evidence – the only evidence available. That review suggests that the most likely site of origin was Haskell County, Kansas, an isolated and sparsely populated county in the southwest corner of the state, in January 1918 [1]. If this hypothesis is correct, it has public policy implications.

But before presenting the evidence for Haskell County it is useful to review other hypotheses of the site of origin. Some medical historians and epidemiologists have theorized that the 1918 pandemic began in Asia, citing a lethal outbreak of pulmonary disease in China as the forerunner of the pandemic. Others have speculated the virus was spread by Chinese or Vietnamese laborers either crossing the United States or working in France.

More recently, British scientist J.S. Oxford has hypothesized that the 1918 pandemic originated in a British Army post in France, where a disease British physicians called "purulent bronchitis" erupted in 1916. Autopsy reports of soldiers killed by this outbreak – today we would classify the cause of death as ARDS – bear a striking resemblance to those killed by influenza in 1918 [2].

But these alternative hypotheses have problems. After the 1918–1919 pandemic, many investigators searched for the source of the disease. The American Medical Association sponsored what is generally considered the best of several comprehensive international studies of the pandemic conducted by Dr. Edwin Jordan, editor of The Journal of Infectious Disease. He spent years reviewing evidence from all over the world; the AMA published his work in 1927.

Since several influenza pandemics in preceding centuries were already well-known and had come from the orient, Jordan first considered Asia as the source. But he found no evidence. Influenza did surface in early 1918 in China, but the outbreaks were minor, did not spread, and contemporary Chinese scientists, trained by Rockefeller Institute for Medical Research (now Rockefeller University) investigators, stated they believed these outbreaks were endemic disease unrelated to the pandemic [3]. Jordan also looked at the lethal pulmonary disease cited by some historians as influenza, but this was diagnosed by contemporary scientists as pneumonic plague. By 1918 the plague bacillus could be easily and conclusively identified in the laboratory [3]. So after tracing all known outbreaks of respiratory disease in China, Jordan concluded that none of them "could be reasonably regarded as the true forerunner" of the pandemic [3].

Jordan also considered Oxford's theory that the "purulent bronchitis" in British Army camps in 1916 and 1917 was the source. He rejected it for several reasons. The disease had flared up, true, but had not spread rapidly or widely outside the affected bases; instead, it seemed to disappear [3]. As we now know a mutation in an existing influenza virus can account for a virulent flare-up. In the summer of 2002, for example, an influenza epidemic erupted in parts of Madagascar with an extremely high mortality and morbidity; in some towns it sickened an outright majority – in one instance sixty-seven percent – of the population. But the virus causing this epidemic was an H3N2 virus that normally caused mild disease. In fact, the epidemic affected only thirteen of 111 health districts in Madagascar before fading away [4]. Something similar may have happened in the British base.

Jordan considered other possible origins of the pandemic in early 1918 in France and India. He concluded that it was highly unlikely that the pandemic began in any of them [3].

That left the United States. Jordan looked at a series of spring outbreaks there. The evidence seemed far stronger. One could see influenza jumping from Army camp to camp, then into cities, and traveling with troops to Europe. His conclusion: the United States was the site of origin.

A later equally comprehensive, multi-volume British study of the pandemic agreed with Jordan. It too found no evidence for the influenza's origin in the Orient, it too rejected the 1916 outbreak among British troops, and it too concluded, "The disease was probably carried from the United States to Europe [5]."

Australian Nobel laureate MacFarlane Burnet spent most of his scientific career working on influenza and studied the pandemic closely. He too concluded that the evidence was "strongly suggestive" that the disease started in the United States and spread with "the arrival of American troops in France [6]."

Before dismissing the conclusions of these contemporary investigators who lived through and studied the pandemic, one must remember how good many of them were. They were very good indeed.

The Rockefeller Institute, whose investigators were intimately involved in the problem, alone included extraordinary people. By 1912 its head Simon Flexner – his brother wrote the "Flexner report" that revolutionized American medical education – used immune serum to bring the mortality rate for meningococcal meningitis down from over 80% to 18%; by contrast, in the 1990s at Massachusetts General Hospital a study found a 25% mortality rate for bacterial meningitis. Peyton Rous won the Nobel Prize in 1966 for work he did at the institute in 1911; he was that far ahead of the scientific consensus. By 1918 Oswald Avery and others at Rockefeller Institute had already produced both an effective curative serum and a vaccine for the most common pneumococcal pneumonias. At least partly because of the pandemic, Avery would spend the rest of his career studying pneumonia. That work led directly to his discovery of the "transforming principle" – his discovery that DNA carries the genetic code.

The observations of investigators of this quality cannot be dismissed lightly. Jordan was of this quality.

More evidence against Oxford's hypothesis comes from Dr. Jeffrey Taubenberger, well-known for his work extracting samples of the 1918 virus from preserved tissue and sequencing its genome. He initially believed, based on statistical analysis of the rate of mutation of the virus that it existed for two or three years prior to the pandemic. But further work convinced him that the virus emerged only a few months prior to the pandemic (personal communication with the author from J Taubenberger, June 5th 2003).

So if the contemporary observers were correct, if American troops carried the virus to Europe, where in the United States did it begin?

Both contemporary epidemiological studies and lay histories of the pandemic have identified the first known outbreak of epidemic influenza as occurring at Camp Funston, now Ft. Riley, in Kansas. But there was one place where a previously unknown – and remarkable – epidemic of influenza occurred.

Haskell County, Kansas, lay three hundred miles to the west of Funston. There the smell of manure meant civilization. People raised grains, poultry, cattle, and hogs. Sod-houses were so common that even one of the county's few post offices was located in a dug-out sod home. In 1918 the population was just 1,720, spread over 578 square miles. But primitive and raw as life could be there, science had penetrated the county in the form of Dr. Loring Miner. Enamored of ancient Greece – he periodically reread the classics in Greek – he epitomized William Welch's comment that "the results [of medical education] were better than the system." His son was also a doctor, trained in fully scientific ways, serving in the Navy in Boston.

In late January and early February 1918 Miner was suddenly faced with an epidemic of influenza, but an influenza unlike any he had ever seen before. Soon dozens of his patients – the strongest, the healthiest, the most robust people in the county – were being struck down as suddenly as if they had been shot. Then one patient progressed to pneumonia. Then another. And they began to die. The local paper Santa Fe Monitor, apparently worried about hurting morale in wartime, initially said little about the deaths but on inside pages in February reported, "Mrs. Eva Van Alstine is sick with pneumonia. Her little son Roy is now able to get up... Ralph Lindeman is still quite sick... Goldie Wolgehagen is working at the Beeman store during her sister Eva's sickness... Homer Moody has been reported quite sick... Mertin, the young son of Ernest Elliot, is sick with pneumonia... Pete Hesser's children are recovering nicely... Ralph McConnell has been quite sick this week (Santa Fe Monitor, February 14th, 1918)."

The epidemic got worse. Then, as abruptly as it came, it disappeared. Men and women returned to work. Children returned to school. And the war regained its hold on people's thoughts.

The disease did not, however, slip from Miner's thoughts. Influenza was neither a reportable disease, nor a disease that any state or federal public health agency tracked. Yet Miner considered this incarnation of the disease so dangerous that he warned national public health officials about it. Public Health Reports (now Morbidity and Mortality Weekly Report), a weekly journal produced by the U.S. Public Health Service to alert health officials to outbreaks of communicable diseases throughout the world, published his warning. In the first six months of 1918, this would be the only reference in that journal to influenza anywhere in the world.

Historians and epidemiologists have previously ignored Haskell most likely because his report was not published until April and it referred to deaths on March 30, after influenza outbreaks elsewhere. In actuality, by then the county was free of influenza. Haskell County, Kansas, is the first recorded instance anywhere in the world of an outbreak of influenza so unusual that a physician warned public health officials. It remains the first recorded instance suggesting that a new virus was adapting, violently, to man.

If the virus did not originate in Haskell, there is no good explanation for how it arrived there. There were no other known outbreaks anywhere in the United States from which someone could have carried the disease to Haskell, and no suggestions of influenza outbreaks in either newspapers or reflected in vital statistics anywhere else in the region. And unlike the 1916 outbreak in France, one can trace with perfect definiteness the route of the virus from Haskell to the outside world.

All Army personnel from the county reported to Funston for training. Friends and family visited them at Funston. Soldiers came home on leave, then returned to Funston. The Monitor reported in late February, "Most everybody over the country is having lagrippe or pneumonia (Santa Fe Monitor, February 21st 1918)." It also noted, "Dean Nilson surprised his friends by arriving at home from Camp Funston on a five days furlough. Dean looks like soldier life agrees with him." He soon returned to the camp. Ernest Elliot left to visit his brother at Funston as his child fell ill. On February 28, John Bottom left for Funston. "We predict John will make an ideal soldier," said the paper (Santa Fe Monitor February 28th, 1918).

These men, and probably others unnamed by the paper, were exposed to influenza and would have arrived in Funston between February 26 and March 2. On March 4 the first soldier at the camp reported ill with influenza at sick call. The camp held an average of 56,222 troops. Within three weeks more than eleven hundred others were sick enough to require hospitalization, and thousands more – the precise number was not recorded – needed treatment at infirmaries scattered around the base.

Whether or not the Haskell virus did spread across the world, the timing of the Funston explosion strongly suggests that the influenza outbreak there did come from Haskell. Meanwhile Funston fed a constant stream of men to other American locations and to Europe, men whose business was killing. They would be more proficient at it than they knew.

Soldiers moved uninterrupted between Funston and the outside world, especially to other Army bases and France. On March 18, Camps Forrest and Greenleaf in Georgia saw their first cases of influenza and by the end of April twenty-four of the thirty-six main Army camps suffered an influenza epidemic [3]. Thirty of the fifty largest cities in the country also had an April spike in excess mortality from influenza and pneumonia [7]. Although this spring wave was generally mild – the killing second wave struck in the fall – there were still some disturbing findings. A subsequent Army study said, "At this time the fulminating pneumonia, with wet hemorrhagic lungs, fatal in from 24 to 48 hours, was first observed [8]." (Pathology reports suggest what we now call ARDS.) The first recorded autopsy in Chicago of an influenza victim was conducted in early April. The pathologist noted, "The lungs were full of hemorrhages." He found this unusual enough to ask the then-editor of The Journal of Infectious Diseases "to look over it as a new disease" [3].

By then, influenza was erupting in France, first at Brest, the single largest port of disembarkation for American troops. By then, as MacFarlane Burnet later said, "It is convenient to follow the story of influenza at this period mainly in regard to the army experiences in America and Europe [6]."

The fact that the 1918 pandemic likely began in the United States matters because it tells investigators where to look for a new virus. They must look everywhere.

In recent years the World Health Organization and local public health authorities have intervened several times when new influenza viruses have infected man. These interventions have prevented the viruses from adapting to man and igniting a new pandemic. But only 83 countries in the world – less than half – participate in WHO's surveillance system (WHO's flunet website http://rhone.b3e.jussieu.fr/flunet/www/docs.html webcite). While some monitoring occurs even in those countries not formally affiliated with WHO's surveillance system, it is hardly adequate. If the virus did cross into man in a sparsely populated region of Kansas, and not in a densely populated region of Asia, then such an animal-to-man cross-over can happen anywhere. And unless WHO gets more resources and political leaders move aggressively on the diplomatic front, then a new pandemic really is all too inevitable.

References
1.Barry JM:
The Great Influenza: the Epic Story of the Deadliest Plague in History First Edition New York: Viking 2004.
2.Oxford JS: The so-called Great Spanish Influenza Pandemic of 1918 may have originated in France in 1916.
Philos Trans R Soc Lond B Biol Sci 2001 , 356:1857-1859. PubMed Abstract | Publisher Full Text
3.Jordan E:
Epidemic influenza First Edition Chicago: AMA 1927.
4.Outbreak of influenza, Madagascar, July-August 2002
Euro Surveill 2002 , 7:172-174. PubMed Abstract | Publisher Full Text
5.Thomson D, Thomson R:
Influenza. Annals of the Pickett-Thomson Research Laboratory First Edition Baltimore: Williams and Wilkens 1934.
6.Burnet FM, Clark E:
Influenza: a survey of the last fifty years Melbourne.: Macmillan Co 1942.
7.Collins SD, Frost WH, Gover M, Sydenstricker E:
Mortality from influenza and pneumonia in the 50 largest cities of the United States First Edition Washington: U.S. Government Printing Office 1930.
8.Ireland MW:
Medical Department of the United States Army in the World War – Communicable diseases First Edition Washington: U.S. Government Printing Office 1928.

Author’s note: The influenza epidemic of 1918 was a disaster of international proportions.
Indeed, as Fred van Hartesveldt notes, “[i]nfluenza undoubtedly killed more in one-fifth
the time than World War I’s soldiers managed with all their machine guns, poison gas, and
rapid-fire artillery.” The world-wide death toll of the epidemic has been estimated at somewhere
between 20 and 40 million. Spanish Influenza has even been held responsible for
crucial developments in the Great War. Dr. Woods Hutchinson, a local physician, argued
for a Berkeley audience that “it is due to this disease that the German offensive was held
up for two weeks last spring, giving our American boys a chance to do their fine work at
Chateau-Thierry.”

The epidemic came to the University of California in three waves, the first and most
serious in October and November of 1918. During this period almost a quarter of the
campus community contracted the disease. It resurfaced briefly in December and again in
January, causing Spring semester to be delayed by two weeks. Though the State Hygiene
Laboratory on the university campus developed a vaccine in late October by using blood
donated by Berkeley students, the serum was distributed first to the military camps and
secondly to students and by the time it was made generally available, the epidemic had
largely run its course.

Abstract: Local epidemic curves during the 1918–1919 influenza pandemic were often characterized by multiple epidemic waves. Identifying the underlying cause(s) of such waves may help manage future pandemics. We investigate the hypothesis that these waves were caused by people avoiding potentially infectious contacts—a behaviour termed ‘social distancing’. We estimate the effective disease reproduction number and from it infer the maximum degree of social distancing that occurred during the course of the multiple-wave epidemic in Sydney, Australia. We estimate that, on average across the city, people reduced their infectious contact rate by as much as 38%, and that this was sufficient to explain the multiple waves of this epidemic. The basic reproduction number, R0, was estimated to be in the range of 1.6–2.0 with a preferred estimate of 1.8, in line with other recent estimates for the 1918–1919 influenza pandemic. The data are also consistent with a high proportion (more than 90%) of the population being initially susceptible to clinical infection, and the proportion of infections that were asymptomatic (if this occurs) being no higher than approximately 9%. The observed clinical attack rate of 36.6% was substantially lower than the 59% expected based on the estimated value of R0, implying that approximately 22% of the population were spared from clinical infection. This reduction in the clinical attack rate translates to an estimated 260 per 100 000 lives having been saved, and suggests that social distancing interventions could play a major role in mitigating the public health impact of future influenza pandemics.

In 1918, an outbreak of influenza swept over the earth, becoming the deadliest pandemic in history. Between 50 and 100 million people died, including 675,000 Americans. (1) One-third of the world's population and one-fourth of Americans were infected. (2)

In this article, we provide an overview of how the pandemic affected American society. We also examine the impact on psychiatric hospitals. As we prepare for the next flu pandemic, the lessons learned from the 1918 outbreak remain relevant and instructive.

A Global Catastrophe

Despite intensive investigations, much about the virus (H1N1) that caused the 1918 pandemic remains a puzzling mystery. (2) We do know that it first infected birds before transforming to infect swine and humans. (3) Although some evidence suggests that human infection began in Canton, China, most historians say the pandemic began in Kansas near an Army base in February 1918. (1,3)

Fort Riley was a huge Army training facility in Kansas that had nearly 60,000 soldiers. As Barry states in The Great Influenza: The Epic Story of the Deadliest Plague in History, "It is impossible to prove that someone from Haskell County, Kansas, carried the influenza virus to Camp Funston [which contained Fort Riley's infirmary]. But the circumstantial evidence is strong." (1) At Fort Riley thousands of military personnel developed the flu in the spring, summer, and fall of 1918. The first official influenza sick call at Camp Funston occurred on March 4, 1918, and within three weeks at least 1,000 soldiers required hospitalization for severe symptoms. (1)

[ILLUSTRATION OMITTED]

The virus spread east in the United States and on to Europe, Asia, the South Pacific, and Australia. By May 1918 influenza was epidemic in Spain. Spain, a neutral country during World War I, did not have press censorship. Thus, reports of the large numbers of influenza cases circulated widely, and the illness became known as the Spanish Flu or La Grippe. (1) Influenza advanced around the world in three waves: spring 1918, fall 1918, and winter 1919. (2)

The 1918 flu had three significant clinical features: rapid death, fatal secondary bacterial infection, and highest mortality among those 20 to 40 years old (People born before 1889 were thought to have some immunity from exposure to a prior epidemic (2)). More U.S. soldiers died from the flu than from combat. (4)

Reactions at Home

Denial. Many Americans denied the outbreak's seriousness, based on limited news coverage and the stance of local and federal authorities. For example, officials in Philadelphia downplayed the significance of early cases and, in fact, encouraged large public gatherings. (5) Yet if the public had known of the flu's dangers, more might have participated in quarantine efforts which, when complete, were surprisingly effective.

Hatchett et al compared the flu's peak mortality rates in different U.S. cities to demonstrate the proven effectiveness of nonphar-macologic interventions (NPIs). (5) Communities that used several such interventions (e.g., preventing public gatherings and closing schools) had a reduction in peak incidence of influenza cases by 50%, although the overall number of cases was reduced by only 20% (still an impressive figure). Philadelphia had one of the highest mortality rates of major U.S. cities, attributed to a failure to implement NPIs and to allowing a citywide parade on September 28, 1918, which 200,000 people attended.

Mistrust. Some saw influenza as a German weapon brought to the United States by U-boats. (1) Others blamed the outbreak on immigrants. For example, Denver residents singled out Italians. (1)

With denial of the pandemic becoming impossible as more people died, the public lost trust in local and federal authorities. As Barry says, "The terror among Americans about the 1918 influenza was a direct result not of the disease itself but the result of the way in which authorities and the media systematically destroyed trust." (6)

Panic. Many feared that influenza would not only disrupt life but also would cause the end of civilization. (1) Suicide rates in the United States increased during the pandemic. (7) In rural areas, such as in Kentucky, flu victims starved to death because their neighbors were afraid to bring them food. (6) In many U.S. cities, social gatherings (e.g., church services and public performances) were suspended and schools were closed. (8) Corpses remained uncollected in homes and on streets, and morgues overflowed with bodies. (1)

The Psychiatric Impact

When considering the psychiatric impact of the virus that caused the 1918 pandemic, one has to remember the state of psychiatric research at the time. With that consideration in mind, influenza infection was said to cause delirium, described succinctly by a French clinician (quoted by Barry) as follows: "The mental disturbances during Influenza sometimes took the form of acute delirium with agitation, violence, fear and erotic excitation." Less commonly, "The main symptom was of a depressive nature ... fear of persecution." (1) A U.S. Army report (quoted by Barry) noted, "Nervous symptoms appeared early, restlessness and delirium being marked." (1)

Some patients reportedly became self-destructive as a result of delirium. Starr, who was a medical student during the pandemic, described how "Mike a piano mover was poised on the window ledge ready to jump." Following Starr's intervention, "Mike, delirious had turned the bed over on top of himself and was moving up the ward on his back. He lasted only a few hours after that." (8)

After the pandemic, influenza was an area of interest for psychiatric researchers. In 1926, Menninger hypothesized that pregnant women who had influenza produced children who later developed schizophrenia. (9) Others speculated that the infection disturbed fetal development and led to lower birth weights, and that this was the mechanism through which influenza led to schizophrenia. (10) While these hypotheses have not been proven, the long-term effect of in utero infection remains an area of schizophrenia research interest. (11)

Effect on Psychiatric Hospitals

Public mental hospitals in the United States in 1918 were self-contained communities, (12) but this relative isolation did not spare them from the pandemic. Many hospitals remained open to admissions, providing a source of infection. The Worcester State Hospital (Massachusetts) 1918 annual report states:

In 1918, the hospital's population was 1,774, yielding a 0.11% death rate from influenza alone or a combined "excess" pneumonia and influenza death (CEPID) rate of 0.67%, which is similar to the CEPID death rate of 0.65% in cities employing several quarantine-type control measures. (5) This CEPID figure is based on the assumption that 10 of the 31 pneumonia cases reported in 1918 at Worcester State Hospital were "excess" (i.e., beyond what would have been expected in a typical year). Prior to the epidemic, about 21 patients died from pneumonia annually.

At Dorothea Dix Hospital in North Carolina, only 18 patients and 2 staff members died as a result of the flu, and only 317 patients had the flu. (14) At that time the hospital's patient population was approximately 1,900. (15) At the New Hampshire State Hospital, "During the fall of 1918 we took our brunt of the influenza epidemic, 243 cases developing within the hospital with 16 deaths." (16) During the flu outbreak, the hospital had an average census of 1,368 patients.

Although the three state hospitals we examined did not seem to be significantly affected by the pandemic, Torrey and Miller report that the pandemic had a large impact on patient populations: "The only event that slowed this inexorable ascent [of insanity] was the influenza pandemic of 1918, which temporarily decreased the prevalence of insanity by killing large numbers of patients in the asylums." (17)

Across the Atlantic, in Amsterdam the pandemic was at its height in October of 1918, and admissions to mental hospitals actually increased during that month (although not a statistically significant difference). There is no evidence of any attempt to deny admission to patients to achieve quarantine. (18)

Final Thoughts

The 1918 pandemic offers important lessons for the next influenza outbreak. As Barry points out, the government needs to be honest and open to achieve positive results. (6) It's important to note that in many instances quarantine did reduce morbidity and mortality.

Yet it's remarkable how little the pandemic of 1918 is noted or discussed today, particularly outside academic circles. If not for the current concern about the avian flu, one has to wonder if this historic event would have continued to be neglected. After all, the human ability to forget, deny, and avoid unpleasant topics and memories is extraordinary. Langer's An Encyclopedia of World History, published just 40 years after the pandemic, fails to note it and the 50 to 100 million people who died. (19) But there are still some who remember the pandemic firsthand: Dr. Bazemore's father, now 101 years old, recalls running errands for ill people in Massachusetts while a Boy Scout during the outbreak.

References
1. Barry JM. The Great Influenza: The Epic Story of the Deadliest Plague in History. New York: Viking; 2004.
2. Taubenberger JK, Morens DM. 1918 Influenza: the mother of all pandemics. Emerg Infect Dis 2006;12(1):15-22.
3. Kilbourne ED. Influenza pandemics of the 20th century. Emerg Infect Dis 2006;12(1):9-14.
4. Byerly CR. Fever of War: The Influenza Epidemic in the U.S. Army During World War I. New York: New York University Press; 2005.
5. Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proc Natl Acad Sci U S A 2007;104(18):7582-7.
6. Barry JM. What the 1918 flu pandemic teaches us. Yesterday's lessons inform today's preparedness. MLO Med Lab Obs 2006;38(9):26,28. http://www.mlo-online.com/articles/0906/0906clinical_issues.pdf.
7. Wasserman IM. The impact of epidemic, war, prohibition and media on suicide: United States, 1910-1920. Suicide Life Threat Behav 1992;22(2):240-54.
8. Starr I. Influenza in 1918: recollections of the epidemic in Philadelphia. 1976. Ann Intern Med 2006;145(2):138-40.
9. Menninger KA. Influenza and schizophrenia: an analysis of post-influenzal "dementia precox," as of 1918, and five years later. Am J Psychiatry 1926;82:469-529.
10. Wright P, Takei N, Rifkin L, Murray RM. Maternal influenza, obstetric complications, and schizophrenia. Am J Psychiatry 1995;152(12):1714-20.
11. Susser E, Lin SP, Brown AS, et al. No relation between risk of schizophrenia and prenatal exposure to influenza in Holland. Am J Psychiatry 1994;151(6):922-4.
12. Soreff SM, Bazemore PH. When state hospitals were communities. Behavioral Health Management 2005;25(4):10-12.
13. Eighty-Sixth Annual Report of the Trustees of the Worcester State Hospital for the Year Ending November 30, 1918. Boston; 1919.
14. North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services. History of Dorothea Dix Hospital. www.dhhs.state.nc.us/mhddsas/DIX/history.html.
15. Marge Ororke, a historian for Dorothea Dix Hospital. Raleigh, North Carolina. Personal communication. December 2, 2006.
16. Report of the New Hampshire State Hospital to the Governor and Council for the Biennial Period Ending August 31, 1920. Concord, New Hampshire; 1920.
17. Torrey EF, Miller J. The Invisible Plague: The Rise of Mental Illness from 1750 to the Present. Piscataway, N.J.: Rutgers University Press; 2002.
18. van der Heide DH, Coutinho RA. No effect of the 1918 influenza pandemic on the incidence of acute compulsory psychiatric admissions in Amsterdam. Eur J Epidemiol 2006;21(3):249-50.
19. Langer WL. An Encyclopedia of World History. Boston: Houghton Mifflin; 1958.
BY STEPHEN M. SOREFF, MD, AND PATRICIA H. BAZEMORE, MD
IN THIS DEPARTMENT
we take a look at some of yesterday's treatment, reimbursement, and technology trends--and where they stand now.
ABOUT THE AUTHORS
Stephen M. Soreff, MD, is President of Education Initiatives in Nottingham, New Hampshire, and is on the faculty of Metropolitan College at Boston University, Fisher College, Worcester State College, and Southern New Hampshire University.
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Patricia H. Bazemore, MD, is an Associate Professor in the Departments of Psychiatry and Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester. She also is a member of the medical staff at Worcester State Hospital.
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The Influenza Pandemic of 1918-1919 in the British CaribbeanBy DAVID KILLINGRAY

SUMMARY. The influenza pandemic swept through the Caribbean during the period
October 1918 to March 1919 and resulted in c. 100000 deaths. This article focuses on
the British possessions and is based principally on official reports and the local press. It
looks at how the virus entered and spread through the region, the possible reasons for
variations in levels of morbidity and mortality between islands, popular responses to
the infection, and the mainly fruitless official attempts to arrest and deal with the
disease. Jamaica was the first island to be affected, and along with Belize and Guyana,
suffered most severely. A number of islands, particularly those in the eastern Caribbean,
appear to have escaped relatively lightly. Although all sections of the population
were vulnerable, the heaviest mortality rates were among the very poor, East Indian
immigrant labourers, and native Americans. There was also a high toll among males
aged 15-40. Altogether the death rate from influenza in the British Caribbean was
c.30000. In London influenza was added to the official list of British 'imperial diseases',
and although it was recognized that poverty provided the conditions for the spread of
disease, the resources in the Caribbean were barely used to improve standards of living
and nutrition.

Abstract: For much of history comets have been associated with death and disease. There is increasing evidence that life on Earth originated in comets and other stellar debris. If passing comets have continued to deposit viruses and microorganisms on this planet, this may explain why ancient astronomers and civilizations attributed the periodic outbreak of plague to these stellar objects. Moreover, the subsequent evolution and extinction of life may have been directly impacted by the continued arrival of bacteria, archae, viruses, and their genes from space. On this picture the evolution of higher plants and animals, including humans, would be impacted by the insertion of genes from space, as well as recurrent episodes of pandemic disease. Near-culling pandemics and extinction episodes have in fact been preceded by or followed by inserts of viral genes into survivors who have transmitted these viral elements to their progeny, thereby impacting future evolution. Although ancient fears and reverence of comets may be coincidental with the outbreaks of pandemics, they may also have a factual basis.

The Influenza Pandemic occurred in three waves in the United States throughout 1918 and 1919. Learn more about the pandemic, along with the Nation’s health and the medical care system and how they were affected. Also, take a glance at some people who fought the Influenza in the United States.

Letter from nurse to her friend at the Haskell Indian Nations University, Kansas, October 17, 1918. Bureau of Indian Affairs.

In this letter, a volunteer nurse assigned to various military bases, writes to friend about her experiences. Her initial reaction to death is a window into a personal experience, rather than an official report: "the first one [officer] that died sure unnerved me-I had to go to the nurses' quarters and cry it out."

The influenza pandemic of 1918-1919 killed as many as fifty million people worldwide and affected the vast majority of Canadians. Yet the pandemic, which came and left in one season, never to recur in any significant way, has remained difficult to interpret. What did it mean to live through and beyond this brief, terrible episode, and what were its long-term effects?

Influenza 1918 uses Winnipeg as a case study to show how disease articulated abd helped to re-define boundaries of social difference. Esyllt W. Jones examines the impact of the pandemic in this fragmented community, including its role in the eruption of the largest labour confrontation in Canadian history, the Winnipeg General Strike of 1919. Arguing that labour historians have largely ignored the impact of infectious disease upon the working class, Jones draws on a wide range of primary sources including mothers' allowance and orphanage case files in order to trace the pandemic's affect on the family, the public health infrastructure, and other social institutions. This study brings into focus the interrelationships between epidemic disease and working class, gender, labour, and ethnic history in Canada.

Influenza 1918 concludes that social conflict is not an inevitable outcome of epidemics, but rather of inequality and public failure to fully engage all members of the community in the fight against disease.

Between August 1918 and March 1919 the Spanish influenza spread worldwide, claiming over 25 million lives, more people than those perished in the fighting of the First World War. It proved fatal to at least a half-million Americans. Yet, the Spanish flu pandemic is largely forgotten today. In this vivid narrative, Alfred W. Crosby recounts the course of the pandemic during the panic-stricken months of 1918 and 1919, measures its impact on American society, and probes the curious loss of national memory of this cataclysmic event. In a new edition, with a new preface discussing the recent outbreaks of diseases, including the Asian flu and the SARS epidemic, America's Forgotten Pandemic remains both prescient and relevant. Alfred W. Crosby is a Professor Emeritus in American Studies, History and Geography at the University of Texas at Austin, where he taught for over 20 years. His previous books include Throwing Fire (Cambrige, 2002), the Measure of Reality (Cambridge, 1997) and Ecological Imperialism (cambridge, 1986). Ecological Imperialism was the winner of the 1986 Phi Beta Kappa book prize. The Measure of Reality was chosen by the Los Angeles Times as one of the 100 most important books of 1997.